1991, 11-07 Permit App: 91007663 Water Heater a'c' +i' MECHANICAL PERMIT APPLICATION FORM Do
{ lbSl� \ct�' { 3 Ir,formation Worksheet
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JOB STREET ADDRESS: j (1 3 C) 8' COB B Ce_2,c
CITY/STATE/ZIP: p it ( (( 0-06 PARCEL NUMBER: :
OWNER reP k om_ rn Xo t. 4- PHONE NUMBER: 9a y - Coo()
MAILING ADDRESS: A Ill 30 gS t000dALt ' fed ,/'(i�11�l /,J)Aqq 0{p
(Street) (/(�' (C,e ity/State) (Zip)
CONTRACTOR: ,p flis,�, / (9 I,(,t-e„,,,( LICENSE NUMBER: SE -A 2 -S f - 3 7 a/U T
/ PHONE NUMBER: q619 - / /7 O x 3 (P77
MAILING ADDRESS: Po R 3 Q 1 A o t J7i
(Street) (City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER X EACH
DESCRIPTION •OF UNITS UNIT = AMOUNT
DUCTWORK SYSTEM x$10. 00 =
WOODSTOVE/INSERT x 25. 00 =
GAS WATER HEATER / x 10. 00 = IQ , 00
HEATING EQUIPMENT <100, 000 BTU x 12. 00 =
HEATING EQUIPMENT +100, 000 BTU x 7j.d949
GAS PIPING (1 - -4 OUTLETS) xA:-6&6-
GAS PIPING (5 OR MORE. EACH: ) x 1. 00 =
REFRIG 1-100M BTU (NOT A/C OR HEAT PUMP) x 12. 00 =
REFRIG 101-500M BTU x 20. 00 =
REFRIG 501-1, 000M BTU° x 25. 00 =
REFRIG 1, 001-1,750M BTU x 35. 00 =
REFRIG +1,750M BTU x 60. 00 =
HEAT PUMP & AIR CONDITIONER 0-3 TONS _ _ x 12. 00 =
HEAT PUMP & AIR CONDITIONER 3-15 TONS _ x 20. 00 =
HEAT PUMP & AIR CONDITIONER 15-30 TONS _ x 25. 00 =
HEAT PUMP & AIR CONDITIONER 30-50 TONS _ x 35. 00 =
HEAT PUMP & AIR CONDITIONER +50 TONS _ - x 60. 00 =
VENTILATING FANS x 10. 00 =
EVAPORATIVE COOLERS x 10. 00 =
TYPE I HOOD (PER 12 ' OR 12 ' PTN. OF H:)OD) _ x 50. 00 =
TYPE II HOOD x 10. 00 =
CLOTHES DRYER x 10. 00 =
RANGE x 10. 00 =
GAS LOG x 10. 00 =
MISCELLANEOUS (NOT COVERED ELSEWHERE)_ _ x 10. 00 =
UNLISTED GAS APPLIANCE <400, 000 BTU_ _ _ x 50. 00 =
UNLISTED GAS APPLIANCE >400, 000 BTU_ _ _ x100. 00 =
USED APPLIANCE <400, 000 BTU x 50. 00 =
USED APPLIANCE >400, 000 BTU x100. 00 =
AIR HANDLER <10, 000 ��_� - - _ x 12 . 00 =
AIR HANDLER >10, 000 x 15. 00 =
N O V 6 1991 SUBTOTAL $ Jo ,a)
BUi'LDING c& SAFETY PLUS: PROCESSING FEE + $ 25. 00
EQUALS: TOTAL PERMIT
NOTE: MINIMUM PE• "�IT FEE IS $35.00 FEE DUE _ $ 3�
SIGNATURE aS vet �'�, i i 1,40 11
Spokan • Cou Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
INVOICE AND INSTALLER RECAP SHEET
(INSTALLER TO ATTACH JOB DETAIL-LABOR PRICING WORKSHEET
INSTALLER AND THE CERTIFICATE OF COMPLETION-TO THIS RECAP) PAGE OF
INSTALLATION OFFICE UNIT NO. / i .,-/ /DATE .? . // s�
NOTE: If the Installation office unit
number is different than the SELLING UNIT NO. /�Z6 CHECK NO.
selling unit number, the total
dollar amount is to be atm'd
to the selling unit. DIV.NO. LLD AMOUNT$
FED.I.D.#
UNSOLD LABOR UNSOLD LABOR INSTALL INSTALL
WORKORDER OR SOLD MATERIALS TOTAL TOTAL TOTAL
CUSTOMER NAME SALESCHECK N0. LABOR DUE TO DUE TO WHSE DELIVERY& SUPPLIED COST SELL M/U%
PRODUCT ERROR INSTALL ERROR CHGES HOLING CHGES
khrn . to LI . -- y7 gq'7 3 CC
,C— '.: (-e—C- -C161
L-1 CMZ if'? t1''?.ceA / X-)d ��O 4 . y
..ice
TRANSACTION CODES DETACH BEFORE DEPOSITING ARS -
1. REGULAR INVOICE 8.FREIGHT REMITTANCE ADVICE
2. YOU MEMO FILLS
3. YOUR MEMO 9.DCUT 4 5 9685
4. RETURNED GOODS DOWN1 IF THIS REMITTANCE APPEARS TO BE INCORRECT I
5. ERROR ON INVOICE
6. TRANSPORTATION CHARGES WRITE AT ONCE TO SEARS UNIT PRINTED BELOW
7. YOUR LETTER OR BAL.DUE
INV.DATE INVOICE NO. AMOUNT SUPPLEMENTAL INFORMATION
C MO. DAY YR.
1031910 3500KMEA M. GAUNT
SPOKANE, WA 001029
FORM R&D REV.(8-91)
11 /01 /91 1 OF 1 6461151 i 3500
DATE PAGE NO. CHECK NUMBEri CHECK AMOUNT DUNS N0.(OR VENDOR NO.)
4.ii),
TOTAL $ $ $ $ $ $ $ $ $ $ -
ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. — — —
187-04-000 103-00-000 187-08-000 140-87-001 116-87-000 105-01-000 — — —
14613(2/91)
Sears Forms Management STORE